|Year : 2022 | Volume
| Issue : 4 | Page : 182-186
Morphometry of the tibial footprint of the anterior cruciate ligament in Punjabi population: Magnetic resonance imaging based retrospective study
Seema Sehmi1, Kaur Gagandeep2, Singh Maninder3
1 Professor, Department of Anatomy, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
2 Medical officer, Private Hospital, Government Medical College, Amritsar, Punjab, India
3 Associate Professor, Department of Orthopaedics, Government Medical College, Amritsar, Punjab, India
|Date of Submission||09-Jul-2022|
|Date of Decision||12-Sep-2022|
|Date of Acceptance||13-Sep-2022|
|Date of Web Publication||29-Oct-2022|
E-444,445 Ranjit Avenue, Amritsar, Punjab
Source of Support: None, Conflict of Interest: None
Background: The anterior cruciate ligament (ACL) is responsible for knee joint stability during all possible movements. The purpose of our present study was to estimate normal values of the position and dimensions of the tibial attachment of ACL for its successful reconstruction. Methodology: A sagittal magnetic resonance imaging (MRI) sample of the knee joint of 120 patients (58 men and 62 women) of 18–50 years of age was reviewed. Results: Anterior end of the tibial footprint was located at a mean of 14.92 mm ± 3.42 mm from the anterior end of the tibial plateau. The posterior end of the tibial footprint was located with a mean of 28.76 mm (±7.02) from the anterior end of the tibial plateau. The mean tibial footprint sagittal length was 14.56 mm ± 0.66 mm. The mean anterior cruciate sagittal center was located at 42.62% ±2.99% of the anteroposterior length of the tibial plateau. The present study will provide the baseline morphometric data for the position and size of the tibial footprint of the ACL on MRI in Punjab. Mean roof angle in the present study was 35.16° (±3.49°). Mean ACL-inclination angle was 50.13°(±4.56°). Mean ACL-Bluemensaat angle in the present study was 4.23°(±2.87°). Conclusion: Present study can help surgeons to ascertain the positioning of the tibial tunnel in routine ACL reconstruction as well as revised ACL reconstruction surgeries.
Keywords: Blumensaat's line, knee injury, osteoarthritis, Rauschning line, tibial plateau
|How to cite this article:|
Sehmi S, Gagandeep K, Maninder S. Morphometry of the tibial footprint of the anterior cruciate ligament in Punjabi population: Magnetic resonance imaging based retrospective study. Natl J Clin Anat 2022;11:182-6
|How to cite this URL:|
Sehmi S, Gagandeep K, Maninder S. Morphometry of the tibial footprint of the anterior cruciate ligament in Punjabi population: Magnetic resonance imaging based retrospective study. Natl J Clin Anat [serial online] 2022 [cited 2023 Mar 28];11:182-6. Available from: http://www.njca.info/text.asp?2022/11/4/182/359871
| Introduction|| |
The tibial footprint of the anterior cruciate ligament (ACL) is attached to the anterior part of the intercondylar area of the tibia. It passes posterolaterally folding on itself and flattens up to get attached to the posterior part of the medial surface of the lateral condyle of the femur. The knee joint is the most vulnerable joint in sports injuries and the ACL is the most commonly ruptured ligament of the knee joint. Injury to the ACL predisposes the knee joint to develop osteoarthritis at early stages. Magnetic resonance imaging (MRI) is the most frequent investigation for diagnosing ACL rupture. The most common treatment of ACL rupture is its reconstruction. The aim of successful knee surgery is to achieve normal biomechanics of the joint. ACL reconstructive surgeries give favorable results in terms of joint steadiness, rehabilitation, and recovery in 75% to 97% but the remaining will show ACL graft failure., If the ACL graft is placed more anteriorly than required, it will cause the tightness of the ACL graft and even impingement in the intercondylar area when the knee joint is extended. Similarly, if the graft is placed more posteriorly, it can lead to joint laxity and posterior cruciate ligament impingement and stiffness when the knee joint is extended. Any faulty tibial tunnel positioning can cause ACL graft failures as high as 37%., This research study will establish the morphometric variations of the tibial footprint of ACL and ACL orientations such as roof angle, ACL-inclination angle, and ACL-Blumensaat's angle in the Punjabi population.
| Methodology|| |
The present retrospective study involved the collection of adequate MRI images fulfilling all requirements available during 2021–2022 year from various radiological centers of Amritsar. MRI scan of the knee joint of 120 normal adults (58 men and 62 women) in the age group of 18–50 years were included in the present study after taking ethics committee approval of Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar (letter no. SGRD/IEC/2022-74 dated June 11, 2022). This sample size was selected after power calculation to minimize the type 1 and type 2 errors. The age and sex of each subject were noted. Exclusion criteria included intra-articular pathology, bony morphology, osteophytes, concomitant ligament injuries, and any patellar dislocation. A 1.5 T scanner with proton density fat-saturated sagittal MRI scan with a field of view of 16 cm, slice thickness 3–4 mm, small interslice interval of 0.4 mm, and matrix of 256 × 192 or more in which the tibial footprint clearly seen was selected for taking all the parameters. All the measurements were taken from the anterior end of the tibial plateau to the most anterior and posterior point of the ACL footprint on the tibia along the Staubli and Rauschning line [Figure 1]. This line passes through the posterior corner of the tibial plateau and perpendicular to the tibial axis. This line is the reference line along which length of ACL footprint is measured. The ACL sagittal center is measured from the anterior aspect to the center of ACL tibial footprint along this line and is expressed as percentage. The long axis of the tibial and femur was drawn by joining midpoints taken along the line drawn in the diaphysis of the tibia and femur. Blumensaat's line is a line drawn parallel to the roof of the intercondylar fossa in the sagittal plane. This line is a basis to evaluate the ACL tunnel position after ACL reconstructive surgeries. The first angle to be calculated is the roof angle which is the angle made by femoral axis and Blumensaat's line [Figure 2]. The second angle is the ACL inclination angle formed between the tangent to the anterior aspect of ACL fibers and perpendicular to the tibial axis at the ACL insertion site [Figure 3]. The third angle is the ACL-Blumensaat's angle formed by Blumensaat's line and tangent to the anterior aspect of ACL [Figure 4]. The success of graft placement in ACL reconstruction procedures depends on roof angle and the alignment of the graft should be parallel to the roof of the intercondylar notch. RadiAnt Dicom viewer software version 2021.2.2 by Medixant software (Medixant, Poland) was used for taking the respective measurements. The mean ± standard deviation of all the measurements was calculated. The differences in the measurements between males and females were calculated using Student's t-test and P < 0.05 was considered statistically significant.
|Figure 1: Measurements taken for the tibial footprint of the anterior cruciate ligament (ACL). A: the anterior end of the tibial footprint of ACL (yellow line with dot); B: posterior end of the tibial footprint of ACL (blue line with dot); C: center of the tibial footprint of ACL (yellow dot). D-A is the distance of the anterior end of the tibial footprint of ACL from the anterior end of the tibial plateau. D-B is distance of the posterior end of the tibial footprint of ACL from the anterior end of the tibial plateau. D-E is the anteroposterior length of the tibial plateau (line joining the most anterior point to the most posteriorly placed point on the tibial plateau indicating Staubli and Rauschning Line. ACL: anterior cruciate ligament|
Click here to view
|Figure 2: Roof Angle – Angle formed between femoral axis (A-B) and Blumensaat's line (B-C)|
Click here to view
|Figure 3: ACL-Inclination angle between the tangent to the anterior aspect of ACL (B-C) and perpendicular to the tibial axis (B-D) at the insertion site. ACL: anterior cruciate ligament|
Click here to view
|Figure 4: ACL-Blumensaat's angle between Blumensaat's line (C-D) and tangent to the anterior aspect of ACL (B-C). ACL: anterior cruciate ligament|
Click here to view
| Results|| |
The mean tibial footprint sagittal length in the present study was 14.56 mm ± 0.66 mm with 14.74 mm ± 1.23 mm in males and 14.17 mm ± 0.22 mm in females. The mean ACL sagittal center was 42.62% ±2.99% from the anterior end of the tibial plateau along the same reference line with 42.89% ±0.2% in males and 42.17% ±4.65% in females. All the parameters taken were longer in males than females. A t-test was performed and a P value was calculated for each morphometric data. However, the mean midpoint of ACL was found almost the same in males and females as mean value of 42.62% (±2.99). The mean roof angle in the present study was 35.16° (±3.49°) with 35.01° (±2.41°) in males and 34.89° (±1.98°) in females. No significant difference is found in males and females, i.e. P > 0.05. The mean ACL-inclination angle was 50.13° (±4.56°) with 50.71° (±2.02°) in males and 49.73° (±5.23°) in females with no significant differences in males and females indicated by a P value more than 0.05. The mean ACL-Blumensaat's angle in the present study was 4.23° (±2.87°) with 4.12° (±2.21°) in males and 4.43° (±3.22°) in females with no significant difference in males and females (P > 0.05). Clinically, all three angles of ACL in males and females can be considered almost the same.
| Discussion|| |
Anatomical position placement of ACL graft with either single or double reconstruction techniques is the basic technique for biomechanical stability and impingement-free knee joint. Tibial tunnel placement too anteriorly will lead to horizontally placed graft and postoperatively lead to impingement resulting in graft failures. The posteriorly placed tibial tunnel will lead to a vertically oriented graft, leading to rotational instability. ACL tibial footprint sagittal diameter < 14 mm will favor single-bundle reconstruction and if it is 18 mm or greater, it will favor double-bundle reconstruction of ACL. The size of the tibial footprint between 14 and 18 mm may require a single or double-tunnel technique. The present study showed the mean ACL tibial footprint sagittal length as 14.56 mm ± 0.66 mm with a significant difference among males and females measurements [Table 1]. Tibial footprint sagittal length was reported as 14 mm to 29 mm by Kopf et al. and as 14 mm (±1.97) by Magill et al. However, Staubli and Rauschning [Table 2] recorded the length as 15 mm, Odenstein and Gillquist as 17.3 mm, Morgan et al. as 18 mm, and Girgis et al. as 29.3 mm. The present study records ACL tibial footprint center as 42.62% ±2.99%. However, Raja et al. reports it as 43.51% ±3.1% from the anterior end of the tibial plateau along the Staubli and Rauschning line and Cho et al. records it as 40% of the East Indian population. Roof angle found by Balgovind et al. averaged 36.54° ±4.3° with no significant difference between males and females. This angle was 57° as reported by Fernandez et al., 44° as given by Bouras et al., and 35° on three-dimensional (3D) computed tomography by Uozumi et al. While mean ACL inclination angle in the sagittal plane given by Konarski et al. was 45.4°, 47.4° by Reid, 51°, 55.6° by Gentil, 58.7° by Ahn,, and 58.9° by Kim. ACL-Blumensaat's angle if it is less than or equal to zero or more than 15°, the chances of ACL injury are significantly more. A decreased ACL-Blumensaat's angle indirectly indicates that the graft is lying almost parallel to the Blumensaat's line and the tunnel is placed too anteriorly. It was 4.7° (±3.35°) as given by Raja et al., 1.6° by Gentili et al., and as high as 7.06° by Saxena et al. While the present study showed 4.23 (±2.87) which was closer to the value given by Raja et al.
|Table 2: Comparison of tibial footprint dimensions in different population|
Click here to view
The limitation of the study is the use of MRI as a sole determining factor for an anteroposterior dimension where the individual sagittal image may not represent the exact center of ACL and at the same time projection variability is very common. Second, ACL is a 3D structure and all angles were taken only in the sagittal plane. Third, ACL moves during flexion and extension of the knee which was not taken into account in the static nature of MRI studies. A number of factors are considered in successful ACL reconstruction surgeries and morphometry of ACL tibial tunnel is one of them.
The present study data can help orthopedic surgeons to decide the position and size of the tibial tunnel during ACL graft reconstruction techniques, especially in Punjab. It is advisable to keep the center of the tibial tunnel during single-tunnel reconstruction between the range 38.23% and 45.34% to prevent a too anteriorly and too posteriorly placed ACL graft in the Punjabi population.
| Conclusion|| |
Mean tibial footprint sagittal length in the present study was 14.56 mm ± 0.66 mm. The mean ACL sagittal center was 42.62% ±2.99% from the anterior end of the tibial plateau along the same reference line. The mean roof angle in the present study was 35.16° (±3.49°). The mean ACL-inclination angle was 50.13° (±4.56°). The mean ACL-Blumensaat's angle in the present study was 4.23° (±2.87°).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res 1975;(106):216-31.
Collins SL, Layde P, Guse CE, Schlotthauser AE, Van Valin SE. The incidence and etiology of anterior cruciate ligament injuries in patients under the age of 18 in the state of Wisconsin. Pediatr Ther 2014;4:196.
Noyes FR, Barber Westin SD. Anterior cruciate ligament injury prevention training in female athletes: A systematic review of injury reduction and results of athletic performance tests. Sports Health 2012;4:36-46.
Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K. A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen. Arthroscopy 2007;23:1320-5.e6.
Bach BR, Provencher MT. ACL surgery: How to get it right the first time and what to do if it fails. J Sports Sci Med 2010;9:527.
Engelman GH, Carry PM, Hitt KG, Polousky JD, Vidal AF. Comparison of allograft versus autograft anterior cruciate ligament reconstruction graft survival in an active adolescent cohort. Am J Sports Med 2014;42:2311-8.
Samitier G, Marcano AI, Alentorn-Geli E, Cugat R, Farmer KW, Moser MW. Failure of anterior cruciate ligament reconstruction. Arch Bone Jt Surg 2015;3:220-40.
Morgan JA, Dahm D, Levy B, Stuart MJ, MARS Study Group. Femoral tunnel malposition in ACL revision reconstruction. J Knee Surg 2012;25:361-8.
MARS Group, Wright RW, Huston LJ, Spindler KP, Dunn WR, Haas AK, et al.
Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort. Am J Sports Med 2010;38:1979-86.
Stäubli HU, Rauschning W. Tibial attachment area of the anterior cruciate ligament in the extended knee position. Anatomy and cryosections in vitro
complemented by magnetic resonance arthrography in vivo
. Knee Surg Sports Traumatol Arthrosc 1994;2:138-46.
Ahn JH, Jeong HJ, Ko CS, Ko TS, Kim JH. Three-dimensional reconstruction computed tomography evaluation of tunnel location during single-bundle anterior cruciate ligament reconstruction: A comparison of transtibial and 2-incision tibial tunnel-independent techniques. Clin Orthop Surg 2013;5:26-35.
Bouras T, Fennema P, Burke S, Bosman H. Stenotic intercondylar notch type is correlated with anterior cruciate ligament injury in female patients using magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc 2018;26:1252-7.
Scheffel PT, Henninger HB, Burks RT. Relationship of the intercondylar roof and the tibial footprint of the ACL: Implications for ACL reconstruction. Am J Sports Med 2013;41:396-401.
Iriuchishima T, Ingham SJ, Tajima G, Horaguchi T, Saito A, Tokuhashi Y, et al.
Evaluation of the tunnel placement in the anatomical double-bundle ACL reconstruction: A cadaver study. Knee Surg Sports Traumatol Arthrosc 2010;18:1226-31.
Brophy RH, Selby RM, Altchek DW. Anterior cruciate ligament revision: Double-bundle augmentation of primary vertical graft. Arthroscopy 2006;22:683.e1-5.
van Eck CF, Lesniak BP, Schreiber VM, Fu FH. Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy 2010;26:258-68.
Murawski CD, Wolf MR, Araki D, Muller B, Tashman S, Fu FH. Anatomic anterior cruciate ligament reconstruction: Current concepts and future perspective. Cartilage 2013;4:27S-37S.
Kopf S, Pombo MW, Szczodry M, Irrgang JJ, Fu FH. Size variability of the human anterior cruciate ligament insertion sites. Am J Sports Med 2011;39:108-13.
Magill H, Rudran B, Cullen C, Jain N. Anatomical variations in the tibial insertion of the Anterior Cruciate Ligament: An MRI study. J Surg Surgical Res. 2020;6:171-2.
Kim HK, Laor T, Shire NJ, Bean JA, Dardzinki BJ. Anterior and posterior cruciate ligaments at different patient ages; MR imaging findings. Radiology. 2008;247:826-35.
Frank RM, Seroyer ST, Lewis PB, Bach BR, Verma NN. MRI analysis of tibial position of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2010;18:1607-11.
Ichiba A, Kido H, Tokuyama F, Makuya K, Oda K. Sagittal view of the tibial attachment of the anterior cruciate ligament on magnetic resonance imaging and relationship between anterior cruciate ligament size and the physical characteristics of patients. J Orthop Sci 2014;19; 97-103.
Raja BS, Garg V, Paul S, Singh S, Thomas W, Siddharth RK, et al
. Assessment of anterior cruciate ligament Tibial footprint Sagittal Diameter and Orientation of the ligament in the Intercondylar Notch in Indian Population: A Magnnetic Resonance Imaging (MRI) Analysis. Cureus 2020;12:e7511.
Odensten M and Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am 1985; 67:257-62.
Morgan CD, Kalman VR, Grawl DM. Definitive landmarks for reproducible tibial tunnel placement in anterior cruciate ligament reconstruction. Arthroscopy 1995;11:275-88.
Cho JM, Suh JS, Na JB, Cho JH, Kim Y, Yoo WK, et al
. Variations in menisco femoral ligaments at anatomical study and MR imaging Radiol 1999;28:189-95.
Balgovind RS, Bhole R, Akshay A. Intercondylar notch morphometrics in Indian Population: An Anthropometric study with magnetic resonance imaging Analysis. J Clin Orthop Trauma 2019;10:702-5.
Fernandez JT, Alcoroho JML, Rodriguez-Inigo E. The importance of intercondylar notch in anterior cruciate ligament tears. Orthop J Sports Med 2015;3. doi: 10.1177/2325967115597882.
Uozumi Y, Nagamune K, Nakano N. An automated determination of Blumensaat line using Fuzzy system based on physician experiment from femur CT image. International conference on Fuzzy systems (FUZZ-IEEE), Beijing, China, 2014.6891742.
Konarski A, Strang M, Jain N. The natural orientation of the Anterior cruciate ligament compared to the tibial plateau on magnetic resonance imaging techniques J Orthop 2020;22;422-24.
Reid JC, Yonke B, Tompkins M. The angle of inclination of the native ACL in the coronal and sagittal planes. Knee Surg Sports Traumatol Arthrosc 2017;25:1101-5.
Gentili A, Seeger LL, Yao L, Do HM. Anterior cruciate ligament tear: indirect signs at MR imaging. Radiology 1994;193:835-40.
Cheng YC, Feng JF, HuiLu Y, Zhao YL, Yang ZQ. Diagnostic value of Bluemensaat angle for anterior cruciate ligament injury. Zhongguo Gu Shang 2017;30:726-30.
Saxena A, Ray B, Rajagopal K, D' Souza S. Morphometry and magnetic resonance imaging of anterior cruciate ligament and measurement of secondary signs of anterior cruciate ligament tear. Bratisl Lek Listy. 2012;113:539-43.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]